Contents

[Pages:10]Contents

INTRODUCTION................................................................................................2

PART ONE: COMMON CONDITIONS AFFECTING VOICE

Overall Considerations...................................................................................................4 Voice Therapy..........................................................................................................4 Vocal Fold Surgery...................................................................................................5

Common Conditions Affecting Voice Nodules and Polyps.................................................................................................6 Cysts........................................................................................................................7 Polypoid Degeneration...........................................................................................8 Hemorrhage...........................................................................................................9 Sulcus.....................................................................................................................10 Bowing...................................................................................................................11 Granulomas...........................................................................................................12 Vocal Fold Paralysis and Paresis............................................................................13 Spasmodic Dysphonia...........................................................................................14 Parkinson Disease..................................................................................................15 Muscle Tension Dysphonia....................................................................................16 Paradoxical Vocal Cord Movement......................................................................17 Repetitive Strain Injury..........................................................................................18 Puberphonia...........................................................................................................19 Transgender Voice Problems..................................................................................20

PART TWO: VOICE THERAPY PROGRAMS

Vocal Hygiene...............................................................................................................21 Hydration..............................................................................................................22 Gastric Reflux Treatment......................................................................................24 References for Vocal Hygiene................................................................................26

Voice Production Work: Cohesive Therapy Programs.................................................27 Resonant Voice Therapy........................................................................................28 Vocal Function Exercises.......................................................................................30 Confidential Voice Therapy...................................................................................32 Accent Method......................................................................................................34 Lee Silverman Voice Treatment.............................................................................36 Laryngeal Massage................................................................................................38 Facilitating Techniques..........................................................................................40 Cognitive-Behavioral Therapy...............................................................................42 Body Awareness and Movement Training.............................................................44 Biofeedback Training....................................................................................46 Transgender Voice Treatment................................................................................49 Relaxed Throat Breathing Techniques..................................................................50

Voice Training for Singers............................................................................................52 Theatre Voice Training.................................................................................................54

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Introduction

It is estimated that 3 to 10 percent of Americans experience voice problems at any given moment in time. The cumulative frequency over the life-span is much larger. Assaults from the environment - pollution, sudden changes in humidity or exposure to pharmacological agents - can make vocal fold tissues irritated or vulnerable to damage. In other cases, disease or trauma impairs the vocal folds, larynx or surrounding tissues. Genetic factors also play a role; some individuals' vocal folds appear to be naturally more robust than others. Finally lifestyle choices are significant. About 25 percent of the population engages in work that is "vocally demanding." For these individuals, either their jobs require excessive vocalization or their work environments force them to speak above a high noise level. Examples of professionals with heavy vocal demands include: teachers, lawyers, auctioneers, aerobic instructors, singers, actors and manufacturing supervisors.

These factors, or a combination of them, converge on an organ whose primary function is not voice production at all, but airway protection. It should come as no surprise that clinics see an increasing number of patients whose vocal systems are mismatched to the load being placed upon them. Patients often report significant work loss and early abandonment of careers in occupations with high voice use.

Historically, speech-language pathologists and otolaryngologists encouraged their patients to allow their voices to rest. However, sometimes this simple advice isn't feasible. Telling a politician not to talk is like telling a football player not to get tackled or a ballerina not to get on her toes. For this reason, an emphasis should go beyond therapy, or rehabilitation. Training in optimal usage of the voice under less than ideal circumstances, or habilitation, is also a task set before the speech-language pathologist specializing in vocology. [Vocology is the science and practice of voice habilitation (Titze, 1990; 1993; 1996).]

For these reasons, this Guide to Vocology was developed. It was created as a comprehensive overview of the many and diverse approaches to voice management. Suggested reading lists were developed as completely as possible so that interested readers may continue investigations into the described techniques. As this publication goes to press (Fall 1998), some citations in the reference lists are denoted as "in press," "in review," or "in revision." The reader is encouraged to visit the website of the National Center for Voice and Speech to obtain current publication information. The address is: .

In Part One, many of the common conditions affecting voice and suggested therapies are described. It is prefaced by a general discussion of voice treatment. Of course, the specific treatment program depends on the patient, his or her condition, and on the clinicians caring for the patient. Information about treatment is meant as a general guide for common situations.

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Part Two describes specific voice therapy programs. In addition to more traditional therapy methods, sections such as whole body wellness, theatre voice techniques and training for singers are included. As the recent subspecialty of vocology has evolved, many speech-language pathologists have found that there is much to learn from interdisciplinary investigations.

ACKNOWLEDGMENTS

The authors gratefully acknowledge Grant P60 DC00976 from the National Institute on Deafness and Other Communication Disorders, a division of the National Institutes of Health. The authors also gratefully acknowledge feedback and valuable insights from Michael Johnson-Chase, BA, Daniel McCabe, DMA, Mary Sandage, MA, CCC-SLP, and Ingo R. Titze, PhD.

REFERENCES FOR VOCOLOGY

Titze, I.R. (1990). Vocology. National Association of Teachers of Singing Journal, 46(3), 21-22. Titze, I.R. (1993). Rationale and structure of a curriculum in vocology. Journal of Voice, 6(1), 1-9. Titze, I.R. (1996). What is vocology? Scandinavian Journal of Logopedics and Phoniatrics, 153.

? 1998, National Center for Voice and Speech 3

Overall Considerations

Clinical personnel. Over the past several years, a subspecialty called "vocology" has progressively evolved. Vocology literally means "study of the voice." A vocologist is any person who is specialized in voice, including voice disorders and their management. More broadly, a vocologist may be a speech-language pathologist, an ear-nose-throat doctor, a voice teacher or coach, or any other person with a special interest in voice. At many of the premier voice centers, voice treatment teams ? an otolaryngologist, a speech-language pathologist and, often, a voice educator ? use a cooperative approach to care for their voice patients.

Success of treatment. Treatment success for voice disorders depends on many factors, including the condition being treated and the clinicians treating it. However, one of the most important overall factors is the patient. Patients who are interested in their voices and are motivated to make improvements generally are likely to get the best overall long-term results from treatment. This is partly because such patients tend to follow treatment recommendations.

VOICE THERAPY

How often, for how long? In the United States, most voice therapy involves 1-2 therapy sessions weekly, for about 2 months. There are exceptions discussed in Part Two of this booklet, such as Lee Silverman Voice Treatment (4 visits per week for 4 weeks).

Content of treatment. Almost all voice therapy addresses at least two issues: (1) Voice hygiene, that is, how to take care of the vocal folds by keeping them moist and free from irritants, and (2) Voice production work, that is, how to use the muscles involved in voice to create the best possible sound without injury. Additionally, some voice therapy programs also include (3) Stress counseling, if relevant. Specific approaches to hygiene, voice production, and stress counseling are described in Part 2 of this booklet.

More and more, voice therapy programs are based on scientific research. Some of the methods borrow from the performing arts in singing and theatre, as arts trainers have dedicated decades ? if not centuries ? developing effective ways of training the voice.

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VOCAL FOLD SURGERY

Terminology and general information. Surgery that is performed to improve voice is called phonosurgery. ("Phono--" comes from the Greek word root referring to "sound.") Phonosurgery is not used for all patients with voice problems. Rather, it is reserved for special cases in which the patient, the physician, and the speech-language pathologist feel that it is a good option. Usually, phonosurgery is either preceded by voice therapy, or followed by voice therapy, or both.

Types of surgery. Most phonosurgery can be classified as one of two main types: (1) Laryngeal microsurgery, which involves the use of a microscope to remove small lesions discussed below; or (2) Medialization surgery, which involves moving one or both vocal folds towards the center of the glottis, or injecting one or both folds with material to bulk them up, so that vocal fold contact is good during voicing. A third type of intervention (3) Botulinum toxin ("botox") injection, does not involve surgery per se, but is sometimes considered together with surgical interventions. Botox treatments involve injecting a small amount of the toxin into one or both vocal folds to temporarily weaken them if they are overactive.

After microsurgery for the removal of laryngeal lesions, most clinicians ask their patients to be completely quiet anywhere from 3-10 days. Subsequently, patients resume talking gradually under the guidance of their physicians and speech-language pathologists. Note that most patients are physically able to talk after surgery; voice rest is required to optimize healing.

Medialization surgery, which is mostly used for patients with vocal fold paralysis or paresis (below), is usually followed by careful voice use under the guidance of a speech-language pathologist. More rigorous voice retraining can usually begin after an initial period of several days or a few weeks.

Following botox injections for "spasmodic dysphonia" (described below), most patients have temporary side effects beginning about 1-2 days after the injection. Typical side effects include breathy, weak voice and mild swallowing difficulties, which usually last about 1-3 weeks. Then, voice usually becomes stronger and relatively spasm-free, and swallowing improves. After a period ranging from a few weeks to several months, voice problems tend to recur and the injections are repeated.

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Nodules and Polyps

DESCRIPTION

Nodules and polyps are common, benign (non-cancerous) growths that develop at the middle of the vocal folds. Mature nodules are similar to "calluses" within the vocal fold tissue and usually develop on both vocal folds. Polyps tend to be more fluid-filled than nodules, and visible blood vessels may feed into them. Polyps may develop on one or both vocal folds. Typical symptoms for both nodules and polyps include hoarseness, effortful voice, and rapid vocal fatigue.

CAUSES

Both nodules and polyps are thought to be caused by vocal fold trauma during talking or singing. The reason is that the middle of the vocal folds, where the growths occur, receives the greatest amount of impact during voice production. Other factors may also increase the likelihood that nodules or polyps will develop. Such factors include smoking, alcohol use, caffeine, drying medications, allergies, exposure to noxious chemicals, and gastric reflux.

TREATMENTS

For nodules, voice therapy is almost always recommended as the first line of treatment. In addition to voice hygiene intervention, voice production is usually addressed using Resonant Voice Therapy, Vocal Function Exercises, Accent Method, Confidential Voice Therapy, Biofeedback, or other methods, discussed in Part Two.

In some cases, after voice therapy has been completed, voice is improved but is not yet back to normal. In such cases, patients may wish to talk with their physicians about laryngeal microsurgery and its possible benefits.

For polyps, voice therapy may be recommended as the first part of treatment, as for nodules. However, in some cases, surgery is recommended first, followed by voice therapy. Voice therapy for polyps is usually similar to therapy for nodules.

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Cysts

DESCRIPTION

Cysts in the vocal folds are similar to cysts other places in the body. They are essentially fluid-filled sacs surrounded by a layer of "skin." Often, a single cyst forms at the middle of one vocal fold, where impact stress is greatest. The other vocal fold usually develops a "reactive swelling" caused by the cyst hitting up against it. Although physicians can usually distinguish a cyst from other similar-appearing lesions such as nodules and polyps by regular clinical examination, the final diagnosis can be made only if the cyst is surgically removed and inspected under a microscope.

CAUSES

No one really knows the exact causes of vocal fold cysts. Because they often form at the middle of the vocal fold, where impact stress is the greatest during voicing, most people think that voice use does play some role in their development.

TREATMENT

Cysts do not go away with voice therapy alone. However, voice therapy is usually the first treatment approach, for two reasons. First, the cyst may be surrounded by swelling, and the opposite fold usually has swelling as well; voice therapy should be effective for reducing the swelling, and thus, improving symptoms. Second, the results from voice therapy can help to make the diagnosis: If a lesion goes away with therapy, then it probably wasn't a cyst. If it doesn't go away, then it might be a cyst, and surgery may be appropriate.

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Polypoid Degeneration

DESCRIPTION

Despite the similarity in their names, "polypoid degeneration," also called Reinke's edema, looks a bit different from polyps. Whereas polyps are distinct lesions that usually form at the middle of one or both vocal folds, polypoid degeneration involves irregular swelling and "ballooning" along the whole length of both vocal folds. A tale-tell symptom is extremely low speaking pitch, especially in women.

CAUSES

Often, polypoid degeneration is seen in persons who have used their voices heavily, and who have also been exposed to irritants such as smoke, chemicals, or gastric reflux. Heavy alcohol use may increase the likelihood of this condition.

TREATMENT

Treatment depends on the patient's needs, and the severity of the lesions. If the swelling is so large that it starts to obstruct the airway, surgery is indicated. If, instead, the swelling is slight, then voice therapy is usually used as a first approach. Therapy is often successful at reducing the swelling and improving symptoms.

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